Conservative Femoral Implants, Short Stems

Rev Esp Cir Ortop Traumatol. 2012;56(1):72---79

Revista Espaola de CirugaOrtopdica y Traumatologa

www.elsevier.es/rot

REVIEW ARTICLE

Conse ste

C. Valve

a Servicio db Servicio d

Received 4

KEYWOHip replaShort steConservaimplant

PALABRArtroplacadera;VstagosImplanteconserva

Please ciTraumatol. 2 Correspo

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1988-8856/$rde-Mordta,, D. Valverde-Beldab

e Ciruga Ortopdica y Traumatologa, Hospital Arnau de Vilanova, Valencia, Spaine Ciruga Ortopdica y Traumatologa, Hospital Doctor Peset, Valencia, Spain

August 2011; accepted 22 August 2011

RDScement;ms;tive femoral

Abstract Uncemented hip replacement matches the best results of classic cemented replace-ments. With the aim of preserving bone and soft tissue, implants with shorter stems and proximalmetaphyseal support have been developed. Likewise, the lack of distal load should avoid cor-tical diaphyseal remodelling phenomena and the thigh pain of some cylindrical and wedgeimplants. The resurfacing implant, very popular as a conservative hip replacement in the youngadult, has disadvantages associated with the fragility of the neck and with large head metalfriction torque. Short stem hip replacement may be a reasonable alternative to classic implantsand surface hip replacements. The different designs of conservative short stem implants areanalysed, and are classied according to their morphology and biomechanical characteristics.Some medium term series show promising results. 2011 SECOT. Published by Elsevier Espaa, S.L. All rights reserved.

AS CLAVEstia de

cortos;femoraldor

Prtesis femorales conservadoras. Vstagos cortos

Resumen La artroplastia de cadera no cementada iguala los mejores resultados de las artro-plastias cementadas clsicas. Con el n de preservar el tejido seo y las partes blandas, se handesarrollado implantes con vstagos ms cortos y con apoyo proximal en la metsis. Adems,la ausencia de carga distal evitara los fenmenos de remodelacin cortical diasaria y el dolorde muslo de algunas prtesis de geometra cilndrica o en cuna. Las prtesis de supercie, muypopulares como artroplastia conservadora en el adulto joven, han generado inconvenientesrelacionados con la fragilidad del cuello y con el par de friccin metlico de cabeza grande. Lasprtesis femorales de vstago corto pueden ser una alternativa ventajosa a las prtesis clsicasy a las artroplastias de supercie. Se analizan los diferentes disenos de prtesis conservadorade vstago corto y se clasican segn su morfologa y caractersticas biomecnicas. Algunasseries, a medio plazo presentan resultados prometedores. 2011 SECOT. Publicado por Elsevier Espaa, S.L. Todos los derechos reservados.

te this article as: Valverde-Mordt C, Valverde-Belda D. Prtesis femorales conservadoras. Vstagos cortos. Rev Esp Cir Ortop012;56(1):72-79.nding author.dresses: [email protected], valverde [email protected] (C. Valverde-Mordt).

see front matter 2011 SECOT. Published by Elsevier Espaa, S.L. All rights reserved.rvative femoral implants. Short ms

Short stem results with conservative femoral implants of the hip 73

Introduction

Uncemented hip prostheses have rivalled the best clas-sic cemented prostheses in terms of stability and survival.Femoral imtion and cachieve prcompetesuntil recenreplaceme

Recentfor total hiuncemente

Uncemeent morphor wedge-metaphyseterms of suabsence of

If we acno diaphysosseointegless femorafemoral neof cancellofor a solid

Short-sttially proplong-termphyseal xmechanicaIt has alsothe end oadvisable tnomena asin numerowith thethe neck,metallic frculitis andperipheralshort, thecouples6----alternativethe presejustify thihowever, istrated fuarthroplast

As withconservativattempt tomorphologresults thashort- or m

Howevethat is actsparing themetaphysis

Some mening theirThis could

The prosthesis is xed on the femoral neck and preservesit; the stem is implanted in the metaphysis---diaphysis keep-ing to the necks trabecular structure (Pipino/CFP model).

Like thepla

hysisste

n anype.re acingheria a c

ene

e (Zw),t) arno

ts. Hem wty.

-spa

theesttheving)ck-sn; itis trd oning physeiaphdingn thetionetecithporteses,edit suereod co

nt cotryy (BDshowen BD

sed). Tbe

as obts thplants designed for proximal metaphyseal xa-oated with porous titanium and hydroxyapatiteimary stability and early osseointegration thatfavourably with cemented prostheses that,tly, were considered the gold standard in hipnt.1

studies have revealed that 20-year survival ratesp replacement are lower with cemented than withd prostheses.2

nted femoral stems are designed with differ-ologies and characteristics: cylindrical, conicalshaped, symmetrical, or anatomical. Proximalal-xed stems appear to give the best results inrvival, absence of remodelling phenomena, andthigh pain.1

hieve good, proximal primary xation, we needeal stem extension. Immediate stability and goodration may be achieved with a short-stem or stem-l prosthesis. A conservative prosthesis spares theck and takes advantage of the quality and volumeus bone in the metaphysis and trochanteric areaand durable primary xation.3,4

em or stemless conservative prostheses were ini-osed as an alternative to classic stems afterexperience with prostheses with proximal meta-ation only, where the stem extension has nol function but simply assists with alignment.

been shown that avoiding contact betweenf the prosthesis and the diaphyseal cortex iso prevent the thigh pain and remodelling phe-sociated with it. The recent, ongoing debateus publications about complications associateddesign of resurfacing prostheses (fracture ofacetabular loosening) and with the use of

iction couples (ALVAL [aseptic lymphocytic vas-associated lesions],5 pseudotumours, increasedblood levels of cobalt and chromium ions)----incurrent controversy over metallic friction

puts the short prostheses in a position to be theto resurfacing prostheses. In young patients,

rvation of bone on the femoral side woulds choice. An even more important reason,s that resurfacing prostheses have not demon-nctional results superior to those of a totaly.7

classic femoral prostheses, the various so-callede prostheses of today vary in design. We willdescribe the different implants in terms of their

y, their biomechanical characteristics, and thet have been published, though these are fromedium-term series.r, not all conservative prostheses have a stemually short, nor are they all equal in terms offemoral neck, cancellous bone tissue, and the

.anufacturers have conned themselves to short-classic implants without modifying the design.

result in inferior prosthesis stability.

sis is immetap

Thexatioprotot

Theresurfahemispaxis vi

Short

Fitmornephe(BiomeWe doimplaning a ststabili

Neck

Amongthe oldunderpreseris a nexatioThereis xeobtainmetapimal ddemanbone iResorpbeen dbone wIt is improsthpain. Mimplanradiosttion ana recesitomedensitbone,betwements;decrea(0---45%cannotloss wsuggesMorrey (Mayo conservative) model, the prosthe-nted as a wedge in cancellous bone tissue of the, with a small distal extension for alignment.mless prosthesis, with proximal circumferentiald high neck cut, is modelled after the Santori

re prostheses designed for transitioning from aprosthesis; these have a subcapital cut and solidcal head and are implanted in the femoral neckonical, straight, porous-coated stem.

d classic stems

immer), SMF (short modular femoral hip) (Smithtaperloc microplasty, and balance microplastye shorter versions of the previous, classic stems.t have published results available for theseowever, it remains to be conrmed that shorten-ithout changing its prole does not alter primary

ring prosthesis xed on the neck

conservative prostheses available at this time,concept is the design proposed in 1979 by Pipinoname biodynamic.8 The CFPTM (collum femorisstem (link) evolved from Pipinos model. This

paring prosthesis with collar tted to the neckis a curved, ribbed, and relatively short stem.

iplanar loading to achieve rotational stability. Itthe neck and in metaphyseal cancellous bone,hysiological xation through alignment with theal trabeculae, and its distal end lies in the prox-ysis.9 This is apparently the most technicallysegment to handle: fractures of external corticalproximal femoral diaphysis have been reported.or rounding off of the femoral neck have alsoted, as well as reinforcement in distal corticalradiographic patterns typical of remodelling.10

ant to point out that, in uncemented long-stemthese are the patterns associated with thigh

um-term results published reect a high rate ofrvival, although these were small series.11,12 Ametric analysis (RSA)13 shows low levels of migra-llapse at 2 years. With CFP implants, however,mputerized tomography (CT)-assisted osteoden-study, which can differentiate between bone) in cortical bone and bone density in cancelloused progressive BD loss in proximal cortical bonerst-year (0---8%) and third-year (0---22%) measure-in proximal cancellous bone also progressivelybetween the rst year (0---33%) and the third yearhe authors concluded that metaphyseal xationachieved with the CFP design. No cortical BDserved below the lesser trochanter. This studyat, with this model, the xation is diaphyseal.14

74 C. Valverde-Mordt, D. Valverde-Belda

Prosthesis wedged into the metaphysis

The Mayo stem (Zimmer), rst devised by Morrey in 1984and approved by the Food and Drug Administration (FDA) in1988, has aneck. Its pand femorallel to anthe femur.the externmetaphysisof alignmereveals a 9ical loosenproximal ofractures (tures andyears (6.6%mean folloenergy X-rabone remoimal resorpauthors reltribution din the literbone resorprostheses

ThereosteonecroosteoarthriON, the dato the necthesis, nothe medium

An expefracture fothesis. Thisperi-prosth

The Meneck that aIn the initithe neck bdesign. A pinterface imotion atMetha proin the metcollar or tplasma-sprexternal coand theshort-term

Like thehas a Mayothicker, witerm seriesstudy.23

The Mincurved, con(implant cand its prois one stud

1it is

tion,prodthe

ith aseri

osenubli1---6).

less prosthesis with proximalmferential xation and high neck cut

oxima prosthesis (DePuy J&J) is a stemless femoralt that is much wider proximally and much shortery than other conservative prostheses. It has a lateraling in the cancellous bone of the greater trochanter,advantage of the quality and quantity of cancellousn that area to provide greater rotational stability. Inpatients with good bone quality, metaphyseal load-curs in this impacted cancellous bone. A high neckits medial portion spares the calcar, and the lateralmade at the level of the piriform fossa. The prosthe-proximal circumferential xation to distribute the

nd minimize the risk of fracture due to impaction orion.29 It is double-coated with porous plasma-sprayedm and hydroxyapatite, except at the distal end, whichhed. Primary stability ensures an early osseointegra-d early formation of spot welds and medial and lateralssing that afford a durable xation. DXA studies onntori Custom model (forerunner of the Proxima)strate effective proximal loading with preservation ofdouble-wedge design that preserves the femoralroximal trapezoidal cross-section follows calcaral neck contours, and the distal end runs par-d in contact with the external cortical bone of15 There have been reports of perforation ofal cortical bone,16 resorption of the neck and,15 and cases where there was a high incidencent problems.17 A review of the original series8.2% survival rate for the stem with no mechan-ing15; however, the authors do report cases ofsteolysis (6%) and intra-operative, non-displaced6%). Other authors18 report post-operative frac-stem collapse with radiotransparent lines at 6). In patients with a mean age of 50.8 years and aw-up period of 5.7 years, studies with DXA (dual-y absorptiometry) and a mathematical model fordelling showed signicant remodelling with prox-tion and medial and lateral bone growth. Theate the remodelling to the mechanical load dis-ened by the implant design. Based on data foundature, however, they conclude that there is lessption with short-stem than with most long-stem.16

was also a study comparing patients withsis (ON) of the femoral head and patients withtis of the hip to evaluate the hypothesis that, inmage is not conned to the epiphysis but extendsk and metaphysis. In patients with a Mayo pros-differences in migration or valgus were found in

term.19

rimental cadaver study showed no greater risk ofr the Mayo prosthesis than for the long-stem pros-would be a predictive factor for design-related

etic fractures.20

tha prosthesis (Braun-Aesculap) has a modularllows the cervical angle and offset to be changed.al series, this was the source of failures due toreaking or dislodging. Changes were made in therosthesis biomechanics study with the stem-neckn Metha and similar models showed that micro-the interface may be the cause of failure.21 Thele is similar to that of the Mayo, slightly thickeraphysis. It has metaphyseal anchoring, with norochanteric are. Proximally, it has a porousayed coating, and its distal end rests against thertical bone. It demands meticulous technique,4

few studies that have been published are.22

Metha, the Nanos stem (Smith and nephew)-inspired design; it is collarless and somewhatth a short distal appendage. There is a short-that compares it with the Alloclassic using a DXA

i-Hip (Corin) and the Collo MIS (Lima) have aical prole, with no metaphyseal are. The Aida

ast) is more conical, with a more curved end,le is reminiscent of the Mayo prosthesis. Therey of the Mini-Hip using radiographic geometry

Figureend of

evaluathese

Forder w5-yearfor lobeen p(Figs.

Stemcircu

The primplandistallare lytakingbone iyounging occut incut issis hasload aexpanstitaniuis polistion anbuttrethe SademonCFP stem. It is xed on the femoral neck, and theimplanted in the proximal diaphysis.

24 but there are no published clinical results foructs.cut implant (ESKA)----a rough metaphyseal cylin-small, uncurved, distal appendage----there is a

es with good results,25 but unacceptable ratesing and fracture of the distal extension haveshed.26---28 This implant cannot be recommended


Figure 2 (a) Intra-operative fracture of the external cortical bone from a CFP implant and secondary resorption of the neck(Falez). (b) Remodelling with thickening of diaphyseal cortical bone.

metaphyseal bone and greater density of the periprostheticbone mass.30

Fixing the implant in neutral position, thereby ensur-ing primary stability, demands meticulous surgical techniqueand it requires the use of an external guide to obtain pre-cise neutra

positioning and with the choice of an underdimensionedsize.

Because the initial good results with the Proxima in youngpatients were so promising,31---34 it was possible to expandthe indications to any age up to 88 years.35 There are also

publi

Figure 3the neck; tcortical bonl orientation. It is not very permissive with varus casesMayo conservative implant. (a) Double-wedge stem with proximal cohe proximal wedge follows the medial contour of the femoral neck,e.shed where the Proxima was used for rescue inating. (b) It is implanted in the metaphysis, sparingand the distal extension rests against the external


Figure 4 Metha implant, inspired by the Mayo geometry.

patients wwould have

Prosthetresurfac

The designtion) devicHip Resurf

5of thater

temheretedbut without cement. After a subcapital osteotomy ofmur, it is xed on the neck, replacing the defective

Figure 6ho had implants in the femoral diaphysis thatinterfered with a long-stem prosthesis.36,37

ic head for transitioning froming prosthesis

of the BMHR (Birmingham Mid-Head Resec-

Figuretationthe gre

short-shemispimplanthesisthe fee is intermediate between the BHR (Birminghamacing) prosthesis (Smith and nephew) and the

or fragilelar compon

(a) Silent implant: prosthetic head xed on the neck. Takes any heaProxima implant: high neck cut and neutral orien-e implant. A lateral are lies in cancellous bone oftrochanter. Circumferential metaphyseal xation.

metaphyseal-xed prosthesis. It is a solid metalwith a thick, porous-coated stem that is

in the femoral neck axis like a resurfacing pros-femoral head and using a resurfacing acetabu-ent without insert. It is used in treatment of

d on a 12/14 cone. (b) Osseointegrated silent stem.


the hip when the femoral head is severely deterioratedor necrotic; it is also used for rescue in resurfacing pros-theses, where the femoral component fails more oftenthan the acetabular component and, at close to 40%, frac-ture of the neck is the most common mode of failure.38

The condichoice ofBMHR arelum, and tin comparther superifracture.38

With theuncemente(DePuy J&lable metausing a poallows forceramic, mIt is morephase.

Discussio

Resurfacinyears forare consernot so muBecause thsonable viain the reatures or nofemoral cahead remaNumerousthis prosthated lesionwith destrrequire thand radiogrevision suis not weare microscale metacauses a llesser volusize----aretem.

The conresurfacing

Long-teto or bettses. Metapthigh pain-sion, consand xedous designlesser degrwith classishowed inc

distal (zone 7) BD with short-stem prostheses while, withthe classic stems, BD was reduced in zones 1 and 7; thisoccurred with no clinical or radiographic changes.40 Long-term clinical studies on short-stem or stemless femoralimplants are not yet available, but the articles that have

publin te abellinof ciculoion,ningardindiffort-re isnvasl aporalualulums iseses-p inpanpatiesistegr

ng stocusulars thaive wothsurv

osthll-kn

of

ce le

ict

thor

al D

tione thas forentippeatoe thation of the femoral neck may determine thethe revision implant. The limitations of thethe head size, determined by the acetabu-

he controversial metal-metal couple. Moreover,ison with the BHR, the BMHR has shown nei-or mechanical strength nor greater resistance to

same basic features as the BMHR----coated stem,d, implanted in the femoral neck axis----the SilentJ) has a 12/14 cone that can accept an articu-l or ceramic head with a standard acetabulumlyethylene, ceramic, or metal insert. Thus, ita choice of acetabulum and friction couple:etal, ceramic---polyethylene, or ceramic---metal.versatile and is currently in the clinical trial

n

g hip prostheses have been very popular in recenttreating hip disease in the young adult. Theyvative from the standpoint of the femur butch from the standpoint of the acetabulum.ey require that the femoral head have rea-bility, the head must be cemented. Tiny awsming and cutting may give rise to neck frac-tching that renders the neck fragile. Once thep has been cemented, the rest of the femoralins invisible. The friction couple is metal---metal.6

articles point out the complications specic toesis----aseptic lymphocytic vasculitis and associ-s (ALVAL) and the appearance of pseudotumoursuction of soft tissues around the hip----whichat the patient be closely followed, clinicallyraphically, and necessitate sometimes complexrgery. The effect of cobalt and chromium ionsll known. In contrast to polyethylene, whichmetric-scale particles, these are nanometric-llic particles.39 Thus, while polyethylene wearocalized particle disease, metallic particles----ofme but greater number, owing to their tinydisseminated throughout the circulatory sys-

servative prosthesis may be an alternative toarthroplasty.

rm results with uncemented prostheses are equaler than those with classic cemented prosthe-hyseal-xed femoral implants show the best,free survival rates.1 Having no diaphyseal exten-ervative stems are implanted without cementin the metaphysis or on the neck,4,8,10 the vari-s sparing femoral neck anatomy to a greater oree. DXA studies comparing short-stem prosthesesc, anatomical, uncemented femoral componentsreased proximal (Gruen zone 1) and decreased

beenresultsand thremoddenceis metextenspositio

Reghip, nowith sh

Themally isurgica

Femindividacetab

Thiprosththe hialso exto allprosthosseoinenduricould facetabcouplecorroswell as

Thetive prfor we

Level

Eviden

Con

The au

Ethic

ProtecdeclaranimalConddata aRightdeclarished on medium-term series show promisingerms of primary stability, early osseointegration,sence of thigh pain and undesirable diaphysealg phenomena.4 They also reect a low inci-omplications----provided that surgical techniqueus----because, having no self-aligning diaphysealshort-stem implants generally tend toward varus.g ON in comparison with osteoarthritis of theerences have been found in medium-term resultsstem implants in terms of migration or varus.19

no evidence that functional results with mini-ive surgery are superior to those with traditionalproaches.41

stems with a standard 12/14 cone allow thesurgeon to choose the friction couple and the.

why conservative prostheses----short-stem---may be preferred in surgical treatment ofthe young adult. Persistent good results haveded the indications for conservative prosthesesents of any age for whom an uncemented hipis indicated.35 Once primary stability and earlyation have been accredited, along with anability comparable to the classic stems, researchon (1) the long-term stability and survival of thecomponent and (2) the development of frictiont are increasingly resistant to mechanical wear,ear, breakage, and banging and squeaking as

er noise phenomena.ival rates and long-term results from conserva-eses series will need to be compared with thoseown prostheses in future studies.

evidence

vel: IV.

of interest

s have no conicts of interest to declare.

isclosures

of human and animal subjects. The authorst no experiments were performed on humans orthis investigation.

ality of Data. The authors declare that no patientrs in this article.privacy and informed consent. The authorst no patient data appears in this article.


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Conservative femoral implants. Short stemsIntroductionShortened classic stemsNeck-sparing prosthesis fixed on the neckProsthesis wedged into the metaphysisStemless prosthesis with proximal circumferential fixation and high neck cutProsthetic head for transitioning from resurfacing prosthesisDiscussionLevel of evidenceConflict of interestEthical Disclosures

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Conservative Femoral Implants, Short Stems

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